A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

Check the client's current fingerstick blood glucose.

Obtain blood pressure and heart rate.

Administer a PRN dose of regular insulin.

Give the client 4 ounces (120 mL) of orange juice.

Provide the client with 1/2 cup (120 mL) diet carbonated soda.

Answer and Explanation

Correct Answer : A,D

Choice A reason: Checking the client's current fingerstick blood glucose is important to determine if the confusion and weakness are due to hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

Choice B reason: Obtaining blood pressure and heart rate is useful for a general assessment but is secondary to assessing blood glucose levels in this scenario.

Choice C reason: Administering a PRN dose of regular insulin is not appropriate without first determining the client's blood glucose level. If the client is hypoglycemic, insulin could worsen the condition.

Choice D reason: Giving the client 4 ounces (120 mL) of orange juice is a quick way to raise blood sugar levels if the client is hypoglycemic.

Choice E reason: Providing diet carbonated soda is not effective for treating hypoglycemia because it does not contain sugar to raise blood glucose levels.

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Correct Answer is D

Explanation

Choice A reason: Ignoring the client can escalate the behavior, as individuals with antisocial behavior may act out more to gain attention.

Choice B reason: Introducing him to the newly admitted client and asking him to join the conversation can disrupt the admission process and does not address the client's behavior appropriately.

Choice C reason: Encouraging him to go to the nurse's station and talk with another nurse may be an option, but it does not directly address the client's need for immediate attention.

Choice D reason: Informing him that the nurse is busy and will talk to him later sets clear boundaries and allows the nurse to complete the admission process without disruption.

A. Observe neck for jugular vein distention. B. Monitor oxygen saturation via continuous pulse oximetry. C. Notify healthcare provider to prepare for pericardiocentesis. D. Assess for paradoxical blood pressure.

Correct Answer is C

Explanation

Choice A reason: Observing for jugular vein distention is important but not the immediate intervention.

Choice B reason: Monitoring oxygen saturation is necessary but secondary to preparing for pericardiocentesis.

Choice C reason: Pericardiocentesis is the definitive treatment for cardiac tamponade, and notifying the healthcare provider to prepare for this procedure is the most important intervention.

Choice D reason: Assessing for paradoxical blood pressure helps confirm cardiac tamponade but does not address the immediate need for treatment.

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A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The psychiatric nurse is talking to a newly admitted client when another male client, who is diagnosed with antisocial behavior, intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" How should the nurse respond to this client?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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